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Search results for "Latent Errors"
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Study
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019 Aug 26; [Epub ahead of print].
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.
Journal Article > Study
A quality improvement initiative to reduce safety events among adolescents hospitalized after a suicide attempt.
Noelck M, Velazquez-Campbell M, Austin JP. Hosp Pediatr. 2019;9:365-372.
Journal Article > Review
Cohen R, Ning S, Yan MTS, Callum J. Transfus Med Rev. 2019:33:78-83.
Inaccurate patient registration can result in information gaps that contribute to delay, misunderstandings, and harm. This review discusses registration errors in the blood transfusion process. The authors discuss how problems can occur during various stages in the transfusion process and result in blood-type discrepancies. They suggest improved reporting of identification mistakes and use of photo identification tools as strategies to prevent patient harm associated with registration errors.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
Journal Article > Commentary
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.
Journal Article > Study
The relationship between organizational leadership for safety and learning from patient safety events.
Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.
The role of organizational leadership in ensuring patient safety has been recognized by accrediting organizations such as The Joint Commission, who issued a sentinel event alert calling attention to the issue and have also developed leadership standards. This Canadian study sought to quantify the relationship between leadership and organizational learning from safety events, and found that hospitals with stronger safety leadership structures demonstrated a greater capacity to learn from errors and near misses. This relationship was particularly true for smaller hospitals. An AHRQ WebM&M perspective discusses how one hospital responded to a never event.